Friday, January 27, 2012

Haunting Music



Today in the hospital we were all surprised to hear strains from a harmonica playing "Somewhere Over the Rainbow," "Silver Bells," and other gentle favorites in the preoperative holding area. It was a patient playing in his stretcher - hospital gown, I.V., and all. Hearing soothing music played live in a setting in which such a gift is completely unexpected is indescribable. When he came out of surgery he played again. We could hear soft harmonica music from the area in the recovery room reserved for people who are going to be fast-tracked home. What a beautiful visitation for our not-so-hallowed halls. I have permission from "Harmony Hank," as I'll call this patient, to share this memento of those moments here. On rare occasions, magic does happen in the hospital!

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There are some works of art that have captured my heart forever and will always be on my list of favorite or "most influential" works or "works I love most."

Then, among these, there are those I cannot, cannot, cannot imagine my life without. They have taken root inside me and are woven into my permanent intellectual and psychic fabric. I cannot shake them. They are part of me. They haunt me. They possess me like spirits inside.

Liszt's Piano Sonata in B minor, which I've recently been re-obsessed with in light of an announcement that Philippine concert pianist Cecile Licad will be performing it in Boston next month, and which I happened to look up TODAY only to learn that it premiered ON THIS DAY in 1857, is one of those latter works.

For me it will always be inextricably intertwined with Frederick Ashton's ballet Marguerite and Armand, and frankly if I didn't know better I would have thought, listening to the music, that Liszt had written it specifically for Alexandre Dumas fils' story The Lady of the Camellias, the subject of Ashton's ballet. I like to think Liszt did have this story in mind; the play premiered in Paris in 1852, Verdi's opera La Traviata opened in 1853, and Liszt composed the sonata in 1852 and 1853 and published it in 1854. Coincidence? Moreover he had been romantically involved with Marie Duplessis, the inspiration for the character of Marguerite Gautier, between 1845 and 1847. Surely the Lady of the Camellias was at least an indirect inspiration to the Sonata in B minor?

Ashton describes seeing the ballet unfold in his mind upon hearing the sonata on the radio. One might say that because he was a talented choreographer he was able to fit the ballet to the music, but once you see the ballet, you realize that it's also the other way around: the sonata follows the story EXACTLY. The best Youtube version I could find is between time index 42:55 and 1:12:30 of this Youtube upload of the documentary Nureyev: I Am a Dancer. Fonteyn and Nureyev, for whom the ballet was created by Ashton, will always be THE Marguerite and Armand, to my mind. Sylvie Guillem may have had more acrobatic technique, but she didn't have the soul for it. Tamara Rojo, though, who recently danced the role in London, may have been able to bring both qualities together - flawless technique and mature artistry. I'd love to see her Marguerite.

As for the sonata, my favorite recording of it is still Alfred Brendel's from 1981, but Andre Watts played a stunning version in Tokyo in 1988, and Evgeny Kissin's is amazing too. The piece epitomizes the Romantic period. It's almost PAINFULLY emotional and unapologetically melodramatic. But it also expresses what we mere mortals have no words to express, and sometimes we need that kind of intensity, especially in a world that holds the UN-emotional - rational and the scientific - so dear.

Sunday, October 16, 2011

What is Death


I've only had to declare death a couple of times. Once in a three-year-old and once in an adult. In each case the heart had stopped beating. Death was clear.

Brain death is tougher to cope with, both clinically and psychologically. I imagine it would make anyone want to say, at some point, "Are you sure? Are you really sure? How do you know? How can you be sure?" Some times when brainstem function is gone and seems clearly irretrievable, there remains a good, strong heartbeat. Strong. Vital signs vigorous.

At one point this month, as I often do around Halloween, I was watching an old episode of the T.V. Show Ghost Whisperer. I enjoy ghost stories. I think whether or not one believes in a soul that can live on after bodily death, ghost stories can be interesting and appealing because everyone can relate to the feeling of being haunted or wanting to haunt. Even the impulse to visit places we haven't seen in years is this kind of gravitation toward haunting. The place still haunts us, and we want to return to haunt it for bit.

In this episode the main character, who is able to see and speak to spirits, receives signs and visions from a man whose body is in a coma but whose soul longs to break free and move on. His family is reluctant to remove life support, so he remains tethered, unable either to wander as an earthbound spirit or cross into a realm of peace that lies beyond this world. Every time I walk into an ICU I think of this episode. Even if ghosts and spirits don't exist, how can we know whether some remote corner of a patient's consciousness feels this sense of being trapped, tethered to ventilators and tubes?

If a family makes a decision to release their loved one and permit the life-giving gift of organ donation, I think of how painful it must be to leave the bedside for the last time. I've heard the sobbing of parents and siblings as I've waited to bring a brain-dead person to the O.R. for organ removal. I've watched a woman tearfully thank the doctors and nurses on her way out of the ICU for the last time as she leaves her sister in our care. I've looked down at someone younger than myself, thinking, "Your life was just starting," and felt sick and sad. Yet the automatic drill sergeant in my mind kicks right in: Not now. No time for feelings now. You have a job to do. Make sure all the families waiting for new beginnings today have the best, most well-cared-for organs you can help this patient provide. But I feel sick, I want to say. I want to cry. No. No sick. No cry. You do what you have to do and cry later. So that's what I do.

Anyone who wonders why an anesthesiologist would be needed for organ donation by a brain-dead person clearly has no grasp of what an anesthesiologist's job is. An anesthesiologist's job is to keep a patient's organs well-perfused and well-oxygenated. Usually this is synonymous with keeping a patient alive under anesthesia. In this special case, it means keeping the patient's heart and lung functions stable so that the donated organs can continue to give life in another or several others. I won't lie and say this type of case feels just like any other, even like just another cardiac case. It doesn't. It's strange. The patient is dead in the ways that matter most to his or her loved ones but alive in ways that will matter to others. Dead but not completely dead. I am taking care of a living shell of someone. A body that is dying and that eventually will come to a full stop.

For the anesthesiologist that moment comes when surgeons cross-clamp the aorta (and, if the heart is being removed, cut the heart out). After that, we can just walk out of the room. For the transplant surgeons it's just the beginning; after about four hours of harvesting they must rendez-vous with the organs and recipients at their respective medical centers and keep operating for eight or ten more hours, this time to put the harvested organs into hopeful people who have been waiting for this new start. For us, though, it's time to turn off the machine and leave the patient behind: the only time we ever leave a patient unattended in the room. This always feels eerie and wrong, but after all, what is there to do, when there is no beating heart left, no circulation, no breathing? And at some point, there is an almost-palpable change in the energy in the room. The person does indeed become a shell, with none of the vibe given off by a living individual.

Afterward all sorts of thoughts swirl around. What if that had been my loved one? Or me? What would I have wanted done, or done differently? I had ice cream last week. I hugged the person I love most in the world last night. This person will never do either again. I want to see Florence again before I depart the universe. I want to make croissants from scratch. I want to hear my son play the Bach Double Violin concerto, which he's starting to work on. I want to laugh really hard at a play with my daughter. What else should be on my bucket list? The thoughts just keep coming, when there's time and space for them, and Mr. Mental Drill Sergeant no longer needs to keep me task-oriented.

Organ removal is even more humbling, I think, than cardiac surgery. It's a concrete reminder of our own fragility and our tenuous hold on life. Lately I've been researching my children's ancestry on their father's side as well as mine, and as I go back and back and back many generations, and see birth dates and death dates and marriages - all huge events when we go through them, but mere drops in the ocean of time when you see them listed over the years - I can't help but think of how paradoxical it is that we are so small and insignificant, yet so dear and so meaningful. I also realize that what we pass on in terms of ideas and good actions is so much more important that what we pass on chromosomally. Our lives are so brief, then death comes for us all. There's no avoiding it. This moment is all we have.

Time to go and make the most of it.

Sunday, September 11, 2011

9/11






images by Reuters, Doug Kanter, Shannon Stapleton, and Joe Raedle

Wednesday, August 17, 2011

Moving Beyond Mammy: Why I Strongly Disagree With Some Criticisms of The Help


I read Kathryn Stockett's novel The Help two years ago, when it first became a literary sensation. I loved and was astounded by it; it quickly became one of my favorite books of all time, among novels like Harper Lee's To Kill a Mockingbird, Barbara Kingsolver's Prodigal Summer, Natalie Babbitt's Tuck Everlasting, Marilynne Robinson's Gilead, Mark Salzman's Lying Awake, and now also Sara Gruen's Water for Elephants. It was unexpectedly very personal for me. I grew up in a society where the privileged have help, the help wear uniforms and eat in the kitchen and call their employers their "masters," and in some families the kids are taught "not to get too friendly with the help." I was lucky, though, and had someone like Constantine (portrayed by Cicely Tyson in the photo above): a woman I bonded with who's like a second mom to me, who's now been in our family for forty years and whom I love with all my heart, and who I know loves me with all of hers. Because of her I learned that love transcends a lot of barriers people can try to erect in various situations.

My brief mention of The Help in a blog post from when I first read it in 2009 summarizes the major themes that made me like it so much: "story and story-telling, truth and lies, having a voice and keeping silence and secrets, writing and how it transforms both writer and reader, and the true meaning of dignity and of significance." It's also, one of my friends adds, about "the power you get over your own story when you break the secrets and silence." She and I read it as READERS, I might even venture to say students of literature - but not as scholars of history. For this reason, critics who have blasted both the book and the movie for (supposedly) failing to be true to the historical times in which the novel is set, and for not focusing on Black History and the sufferings endured by Blacks in the South in the 1960's, have irritated me profoundly. The book was not written to be a documentary about the Civil Rights Movement. It was written to be the story of the intertwining lives of three very different, complex, and compelling women. Novels are about CHARACTERS and novel writing is and should be entirely focused on who those characters are and how those identities drive what happens to them.

No one should presume to tell an author, "Your character should have done this" or "done that." Only the author knows her characters well enough to know why those characters do what they do; she then opens up their lives to us in moments, and we can get to know those characters, but not with the intimacy and authority to be able to dictate what their actions should have been. Any such criticisms are projections by readers, which may be out of keeping with the characters' identities and completely untrue to the world of the book. And that, right there, is the problem: people with an axe to grind couldn't accept a CREATED world, the world of the novel, but rather wanted it to be the world as THEY would have it or depict it.

I read the Open Statement to Fans of The Help by Ida E. Jones, National Director of the Association of Black Women Historians (ABWH) and a review by journalist and University of Georgia professor Valerie Boyd, who wrote Wrapped in Rainbows: the Life of Zora Neale Hurston. I sincerely respect the fact that they know much more than most of us about African American history, and I appreciated being educated on perspectives that might not have occurred or been familiar to me, but I couldn't agree with many of the statements they made. Some of them annoyed me because they missed the point, and because by being so ready to criticize the work - perhaps even before reading the book or seeing the film, like some of their commenters, and perhaps because it was not written by a Black woman? - these critics willfully obviated the possibility of appreciating its many gifts.

The ABWH statement asserts, "Portraying the most dangerous racists in the 1960's Mississippi as a group of attractive, well-dressed society women, while ignoring the reign of terror perpetuated by the Ku Klux Klan and the White Citizens Council, limits racial injustice to individual acts of meanness." What a short-sighted attitude. Stockett clearly did not set out to portray "the most dangerous" racists or write another Mississippi Burning. It's unfair to paint her as intentionally "ignoring" the more violent aspects of the 1960's simply because her novel is about the moments behind closed doors, about diaries and journaling, about words on pieces of paper. I thought that was the very beauty of her novel - that it's about these non-spotlighted things. Does EVERY author who chooses to write about Black women have to have a scene in her novel with a burning cross? Is that a requirement? I thought the special thing about this book WAS its focus on the tiniest moments - it's about the little things that aren't so little. The WHOLE POINT of it is that racism isn't just in KKK violence but ALSO, and perhaps even more insidiously, in the fake smiles of the well-dressed hypocrites and the not-so-hidden sneers of day-to-day interactions.

I also COMPLETELY disagree with the description of any of the characters as "asexual, loyal, contented caretakers of whites." There are no Mammies in Stockett's book - just real-seeming, complex women with courage and heart. Each African-American woman in the book had an identity and a personality. There aren't well-developed male characters, but I think it's because another big POINT of this book is the power and impact of WOMEN's relationships with each other - the focus was, rightly, on Skeeter, Abilene, and Minny.

Many object to the fact that a Black male in the book is an abusive alcoholic. This, too, I find immature: the need for only positive portrayals when a given negative element is important to the story. Do people really think just because African Americans suffered for years, and continue to suffer in many ways still, that there were no wife-beaters among them, as there were among Caucasians, back in the 60's? Do all writers have to walk on egg shells and give terrible traits only to white people in their novels? This kind of reverse racism demonstrates some pretty stunted growth. The literature of my own culture suffers from similar post-colonial tensions. Poor us, it cries; look how the Spaniards raped and enslaved and colonized our people, and after them, the British and the Americans. We have to highlight how evil the white people were, and how long-suffering and noble we are. Give me a break. We have to tell the stories as the stories are - that's what writers DO.

At some point, the literature of a people has to move beyond the need to be perpetually and repeatedly social justice literature. Literature should ultimately be about story first and foremost - story and character. I don't think a story about any group is necessarily obligated to speak for "The Experience" of that group; a writer has to be true to the characters she creates, and those characters may NOT be at all representative in the way historical scholars would understand "representative," whatever that means. I thought the women in The Help were all worth "getting to know" for all their different strengths and faults - a sign of good writing and a story worth reading. In the end I always approach novels as being about the novel's characters, NOT about Black people in Mississippi or Native Americans in New Mexico or Haitians in Haiti. In this particular book, the message of having the courage to tell one's story, to use writing as a way of asserting voice, to paint oppressors of any kind as ultimately ridiculous, and to work together in friendship for justice despite danger, comprised such a valuable STORY that I find politicizing it really unnecessary and unhelpful. The characters are strong, courageous, humorous, imperfect, loyal to EACH OTHER, and different from one another. What's so Mammy about that?

There were many other points made in the aforementioned pieces and the comments they generated that inspired only incredulity and disagreement in me. Boyd's soap-boxy review The Help: a feel-good movie for white people can't even leave the anti-white venom out of its title. If a white person wrote something entitled "A Feel-Good Movie for Black People" there would be a public outcry. I am neither a white person nor a Black person and I certainly did NOT feel good about the pain I read about and saw on the screen, but like one African-American woman journalist who left a comment, I felt very good about the love I saw between women friends and the way the women "ultimately save themselves by telling their stories." Boyd's sweeping generalizations and judgments - that Black people would never confide in white people, that no white person would be remarkable enough to earn Black women's trust, that Skeeter was ONLY motivated by ambition as a writer and not by genuine compassion for the Black women working as domestics in her town, that this novel should have encapsulated the experiences of all maids working in Jackson in the 1960's AND been a portrayal of the larger Civil Rights Movement AND (unrealistically) shown a white woman breaking some kind of mold to confront her only circle of friends with their behavioral ugliness - reveal the bigoted stereotypes and narrow view of white people in her own mind. She's supposed to be this accomplished journalist and scholar - yet she can't rise above what one commenter aptly described as "petty grandstanding."

I honestly think a lot of people out there are just plain SORE that a white woman would DARE tell stories from Black women's point of view AND do such an amazing, vivid, compassionate job. Sour grapes, I say. They need to move beyond judging something for what they WANT it to depict and judge it instead by what the author actually set out to do - get into the small moments, the pouring of tea in kitchens and changing of diapers in the nursery, explore the daily moments and relationships in the lives of three characters: Skeeter, Abilene, and Minny. This is what novels do. They are not Civil Rights documentaries. Stockett didn't want to write a novel about the lynching of innocent, persecuted Black men; she wanted to write about courageous, funny, gifted, strong, inspiring women and their friendships, obstacles, trials and choices. I think her incredible writing and her portrayal of these characters has honored women of all races, and she should be praised and thanked for it.

But please don't be like the intellectually lazy commenters under Boyd's review who don't feel like thinking for themselves and have decided instead, based simply on her tirade or other negative hype, to hate The Help already and not bother to read the book or see the movie. Have a little cultural integrity and responsibility and experience the work for yourself, then decide. It deserves that much, if only because it has us all thinking and talking.


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Addendum 8/18/11: for an articulate, balanced, scholarly critical essay on what The Help could have done better, with a concrete and appropriate LITERARY example, check out this wonderful NPR piece by W. Ralph Eubanks: "Eudora Welty's Jackson: The Help in Context." He gracefully avoids undermining his own credibility by not lapsing into shrill, knee-jerk invective and thus successfully invites readers to open their minds and think critically - presumably the desired effect of any good critic.

8/29/11: Another thoughtful critical piece that makes an excellent point.

Thursday, June 30, 2011

To Bare Or Not To Bare


Topless sunbathing is widely accepted in France, where we've spent a lovely vacation visiting my husband's family. Our recent day trip to a beach on the northern coast sparked interesting conversations between my daughter and me and between my husband and me.

On one hand, I think the relative absence of Puritanical sexual repression in Europe, as compared to the United States, has provided some advantages. People are accustomed to seeing bare breasts on billboards and other media from a young age. Breasts therefore need not be objects of shock value or secret, horny fascination. Women are allowed to be comfortable with their own bodies - as they should be - and men allowed to be comfortable with women's bodies in multiple ways without having to be so obsessively titillated by the one aspect of them, their sexuality.

On the other hand, I value modesty. I think there's something to be said for being feminine and even sexy without needing to bare all, for keeping private parts private (and thus in some way sacred, and meant for reverent care) and preserving the meaning of intimacy. My husband pointed out, though, that two-piece bathing suits are already immodest; what's the big deal with doing away with the top piece? (He is, of course, half European.) My young daughter, on the cusp of womanhood, sounds torn between two cultures; she was a little shocked at how easily modesty was abandoned here in France, but also admired young women for their confidence in their bodies regardless of body type.

Not long after our trip to the beach I read the current National Geographic article about child brides in India and Yemen. So much in that article dredged up a lot of anger in me - at how girls and women are still seen around the world as possessions or goods for use, whose worth is directly associated with the integrity of their hymens, whose appearance or even presence is often blamed for what is really the uncontrolled lasciviousness and misogyny of the males around them. Are men all over the world really so incapable of controlling their basest tendencies? Really? Can't the rape just STOP already? What is WRONG with people?

In my mind the jury's still out on topless sunbathing. Where it's commonplace and culturally comfortable, there doesn't appear to be a down side, and there may even be many positives. Women's efforts at extreme modesty elsewhere don't seem to quell the animal frenzy that leads to their victimization by stupid, irresponsible, and worthless men. Perhaps if the whole world would just relax about the human body we could all just step back, appreciate it, and take good care of it.

Saturday, June 11, 2011

Why I Hate Birth Plans


Recently on a physicians' forum I came across a tragic story about a home birth gone bad. The doctors on the forum were mercilessly critical of the individuals involved, but I couldn't disagree with them. Their tone may have crossed the line from anger over the tragedy into disrespect or even cruelty, but I can't say I blame them entirely - there's a part of every conscientious physician that does get enraged over what's perceived to be preventable catastrophe, and sometimes venting the outrage in private (which this forum was supposed to be), among others who understand, can release some of the tension raised by the story.

There seems to be a wide chasm between expectant women who distrust or perhaps even hate doctors and doctors who see themselves as the protectors of human safety and life and who thus sometimes see such mothers-to-be as close-minded, willfully uninformed, and even selfish. From the physician's point of view, a) "natural" isn't synonymous with "safer;" b) pregnancy causes physiologic changes that can sometimes pose real dangers to mother and infant - DANGERS, not just inconveniences or discomfort; and c) a rigid "plan" for birth is nonsensical in light of the possibility of unplanned concerns necessitating prompt and sometimes life-saving intervention.

Don't get me wrong; I firmly believe in women's right to express PREFERENCES and to have those preferences respected as closely as possible when safety allows. Of COURSE I would never insist on placing an epidural in a woman who preferred to give birth without one. But I resent the kind of pseudo-feminist culture that creates guilt or a sense of "failure" in women who feel they would like an epidural to relieve childbirth pain. I've heard it so many times; a tearful woman saying "I'm a failure" because natural childbirth became medically assisted childbirth. No woman should ever feel BAD about bringing a new life into the world. That, and the social signals that engender it, I definitely resent.

And despite the title of this post, I don't actually hate birth plans. I had one myself. I scrapped it in the end and decided to just trust in the process, and take things a step at a time, and actually have face-to-face conversations with my caregivers, but I did draft one. A birth plan that is meant to clarify preferences is a good thing. A birth plan, written or spoken or just held in one's mind, that is meant to be a binding contract for a physician, come hell or high water, is stupid and ultimately, in my opinion, wrong. The priority should be the baby's and mother's SAFETY, not the parents' "birth experience." If the so-called birth "plan" interferes with safety, it has to go, and any parent who insists on adhering to it under such circumstances doesn't deserve to be a parent. What I hate about certain birth plans is the unspoken attitude or culture behind them that seems to declare that nothing is more important than the mother's "birth experience." This is irresponsible and wrong.

So when a screaming doula verbally abused an obstetrician colleague of mine recently for going to stimulate a baby who was cyanotic and was making no respiratory effort - and when I say screaming, I mean I was three doors down attending to someone else and I could hear her yelling at my colleague at the top of her lungs - I felt the same anger that the physicians on the forum were feeling over the home birth disaster. My colleague was doing her JOB, protecting the baby's life and ensuring the mother's safety, according to standards that have been carefully studied, and here was this medically untrained woman interfering with this physician's care and potentially threatening the life of the child by screaming at the doctor that clamping the cord and stimulating the baby were against the parents' wishes. The baby's safety didn't seem to matter; it was all about the parents' wishes. THAT kind of ignorant, selfish "care" is completely inexcusable, yet in certain circles is glorified and touted as advocacy of women's rights and empowerment of mothers. There's nothing empowering about medical ignorance, stubbornness, or selfish adherence to a dream of a birth experience contributing to a child's death.

Here's what I would want all expectant mothers to know about giving birth at our hospital. Pregnancy may be natural, but it can also be dangerous. If you show up at our door, we're going to bend over backward to protect you and your baby, but we're going to do so according to the high standards of safety to which we've been trained to adhere. Please tell us what you prefer, by all means - we do want to create as wonderful a birth experience for everyone as we can - but we also have to put safety above EVERYTHING. We would be bad doctors, and morally culpable people, if we did any less.

Thursday, June 2, 2011

Anesthesia v. The Joint Commission, Part II


Yesterday's post mentioned that the leaders of this country's most important anesthesia organizations had sent a letter protesting several inane mandates that were being imposed or about to be imposed on anesthesia providers by the JCAHO.

This letter, requesting written confirmation that we anesthesiologists and anesthetists could keep our current, safe practices rather than switching to the suggested idiotic, less safe practices, was sent last December.

Now...let the back-pedaling begin!

JCAHO's response arrived at the American Society of Anesthesiologists' desk just about a month ago, and our anesthesia group has been abuzz about it this week.

The highlights:

"Dear Anesthesia Providers:

...Your letter points out that if specially designed processes are followed to accomplish [the task of pre-labeling syringes], labeling a syringe first and later filling that syringe can be accomplished in a consistently safe manner. [REALLY?! YOU DON'T SAY...?! Is that why we've managed to do this for the last several DECADES?! Imagine that!]

...After discussions with the Joint Commission staff, it was decided that it is beyond the scope of this NPSG [National Patient Safety Goals] to detail all of the various safe and unsafe processes in which a syringe could be filled and labeled. The Joint Commission decided to leave the current NPSG as is, which requires all filled syringes to be labeled, and to remove from the FAQ the prohibition against prelabeling...

As a follow-up to the previous discussion, one exception does exist to the requirement that all syringes be labeled...As long as there is no break in the process, labeling is not required during the administration of spinal and epidural anesthetics and analgesics. [Why THANK you! But we already KNEW that, because to require something so USELESS and intrusive would be completely STUPID.]

...The issue of anesthesia professionals (or anyone for that matter) carrying a medication is left to the individual health care organization."

Thank you, JCAHO, for taking our concerns seriously and realizing the idiocy and lack of groundedness-in-reality of so many of your requirements. Keep up the good work. Maybe if you keep paying attention to what you described in your response as "a number of concerns" voiced by many medical practitioners from many different fields, you can make up for your deficiencies in clinical knowledge and practical imagination with responsiveness to those who actually live and work in the real world every single day.

[Photo source here.]